Lynne J. Goldberg

Is it lymphoma or lymphomatoid papulosis

Distinguishing malignancy from premalignant conditions can be difficult. Controversy surrounds both the clinical and histologic criteria used to distinguish lymphomatoid papulosis, a benign disorder, from CD30+ anaplastic large-cell lymphoma. Three case histories illustrate important points in categorizing different lymphoproliferative disorders as benign or malignant. We emphasize a multidisciplinary approach to improve diagnosis and patient management.

Permanent chemotherapy-induced alopecia: Case report and review of the literature

Reversible alopecia following chemotherapy is well recognized and typically not evaluated by dermatologists. However, there are an increasing number of reports of permanent chemotherapy-induced alopecia, typically following high-dose chemotherapy and subsequent bone marrow transplantation. We describe an unusual case of permanent alopecia in a patient who received adjuvant chemotherapy for breast carcinoma, and not a conditioning regimen before bone marrow transplantation. A unique histologic finding of replacement of anagen hair follicles by linear columns of basaloid epithelium is reported. We review the clinical and histologic findings of permanent chemotherapy-induced alopecia and speculate on its pathogenesis.

Nutrition and hair

Healthy-appearing hair is a sign of excellent general health, as well as good hair care practices. Most healthy individuals have adequate nutrients in their diet; however, many people do not have access to good nutrition, and others have medical illnesses that predispose them to nutritional deficiency. This is often reflected in changes of scalp and, at times, body hair. Malnutrition, congenital heart disease, neuromuscular disease, chronic illnesses, malignancy, alcoholism, and advanced age can cause hair to change color, be weakened, or lost. Recognition of the populations at risk for vitamin deficiency is the first step to their detection. Changes in skin and hair can provide clues to the presence of an underlying vitamin deficiency.

Atypical pilar leiomyoma: cutaneous counterpart of uterine symplastic leiomyoma?

Four cases of cutaneous leiomyoma with cytologic atypia are reported. All four cases were adult men ranging in age from 33 to 92 years of age. Clinical diagnoses were diverse and included epidermal inclusion cyst, scar, nevus, dermatofibroma, squamous cell carcinoma, and basal cell carcinoma. Histological examination of all four lesions revealed a relatively circumscribed, mild to focally moderately cellular, dermal proliferation of large, irregularly shaped spindle cells in a fascicular arrangement. Some cells contained large irregular nuclei and abundant cytoplasm; others were multinucleate. Moderate to focal marked pleomorphism and rare mitotic figures were present, raising the possibility of leiomyosarcoma; however, the sparse mitotic activity and low cellularity did not warrant this diagnosis. This study suggests that cutaneous leiomyomas may exhibit bizarre or “symplastic” patterns analogous to their uterine counterparts.

A case report of inflammatory nonscarring alopecia associated with the epidermal growth factor receptor inhibitor erlotinib

Epidermal growth factor receptor inhibitors (EGFRIs) are new anticancer agents that act by inhibiting EGFR signaling transduction pathways, thus decreasing tumor growth. In more than 30 countries, EGFRIs are currently used in the treatment of a number of solid tumors, and other indications are being sought. In the United States, select EGFRIs have been approved in certain patients with non‐small cell lung cancer, metastatic colorectal carcinoma, and advanced squamous cell carcinoma of the head and neck. Various cutaneous side effects of EGFRIs have been reported, including acneiform eruptions, chronic paronychia, xerosis, a seborrheic dermatitis‐like eruption, changes in hair texture, and nonscarring alopecia. We present a 60‐year‐old woman with non‐small cell lung cancer who developed a persistent generalized itchy eruption and progressive nonscarring alopecia shortly after initiation of erlotinib (Tarceva). Scalp biopsy showed near‐equal number of anagen and catagen/telogen hair follicles, and a superficial and deep perivascular lymphoplasmocytic infiltration. These changes are typical of the nonscarring alopecia induced by EGFRIs. Because it is likely that EGFRIs will be increasingly used, dermatopathologists are likely to see more reactions from these agents. Familiarity with their side effects is essential to accurate diagnosis and effective patient management.

Nests with numerous SOX10 and MiTF-positive cells in lichenoid inflammation: pseudomelanocytic nests or authentic melanocytic proliferation?

Pseudomelanocytic nests in the setting of lichenoid inflammation can mimic atypical melanocytic proliferations. Both melanocytic and cytokeratin immunohistochemical stains may be utilized to differentiate these entities. Unlike true melanocytic nests, pseudomelanocytic nests contain Melanoma Antigen Recognized by T‐cells 1 (MART‐1)/ Melan‐A‐positive cells and cells positive for pan‐cytokeratins, CD3 and/or CD68. Recently, rare (1–2 cells/nest) microphthalmia‐ associated transcription factor (MiTF)‐positive cells were also reported in pseudomelanocytic nests. We present a 48‐year‐old man with a 2 × 3 cm violaceous to hyperpigmented, non‐blanching, polygonal patch on the neck. Histopathology showed focal epidermal atrophy, irregularly distributed junctional nests and a lichenoid infiltrate with colloid bodies. Immunoperoxidase studies revealed occasional pan‐cytokeratin and MART‐1/Melan‐A‐positive staining in nests as well as focal S‐100 protein‐positive cells. Importantly, the majority of nests showed numerous cells positive for MiTF and SOX10 (>2 cells/nest and some the majority of cells). This combined staining pattern confounds the above‐described immunohistochemical distinction between pseudo and true melanocytic nests. Clinically felt to represent unilateral lichen planus pigmentosus/erythema dyschromicum perstans and not malignant melanoma in situ, this lesion highlights the importance of clinicopathologic correlation and suggests either a new melanocytic entity or a novel pattern of benign melanocytic reorganization in a subset of lichenoid dermatitides.

PRP with subcorneal acantholysis: case report and review

Although the clinical findings of pityriasis rubra pilaris (PRP) are striking, the microscopic diagnosis can be difficult because changes can be subtle and can overlap with other skin diseases. Suprabasal acantholysis can be seen in PRP, mimicking pemphigus vulgaris. We report a patient with PRP whose initial biopsies demonstrated subcorneal acantholysis mimicking pemiphigus foliaceus.

Type-I cryoglobulinemia-like histopathologic changes in tick bites: a useful clue for tissue diagnosis in the absence of tick parts

Background:  The histopathologic findings of localized reactions to tick bites may present as diagnostic dilemmas, especially if there is no history of a tick bite, or if the ticks mouthparts are not present in the biopsied skin.

Gianotti-Crosti syndrome presenting as lichenoid dermatitis

Papular acrodermatitis of childhood (Gianotti-Crosti syndrome) is an uncommon, self-limited disease characterized by an erythematous papular eruption symmetrically distributed on the face and limbs and mild lymphadenopathy, thought to be of viral origin. The histopathologic findings are nonspecific and include focal parakeratosis, mild spongiosis, superficial perivascular infiltrate, papillary dermal edema, and extravasated red blood cells. Interface changes with some basal vacuolization may be present, but are not a conspicuous feature. We present a 2 1/2-year-old boy with multiple papules and plaques on the face and extremities and cervical lymphadenopathy. Histopathologic analysis showed compact orthokeratosis, focal parakeratosis, hypergranulosis, psoriasiform epidermal hyperplasia, and a dense lichenoid lymphohistiocytic infiltrate with extensive exocytosis of mononuclear cells. Immunoperoxidase staining with CD 1 a revealed clusters of Langerhans cells in the epidermis and in the papillary dermis. In view of the clinical findings, a diagnosis of Gianotti-Crosti syndrome was made. Although there are a few reports describing a lichenoid pattern of infiltration in Gianotti-Crosti syndrome, this histologic pattern is not widely known. This case is presented to illustrate the fact that Gianotti-Crosti syndrome can present as lichenoid dermatitis, and, especially in children, should be added to the differential diagnoses of lichenoid infiltrates.

Autologous Platelet-Rich Plasma for the Treatment of Pattern Hair Loss.

Platelet-rich plasma (PRP) is a solution derived from whole blood that is enriched in the platelet fraction. Platelets serve as a reservoir of growth factors and cytokines. When platelets are activated in vivo, signaling molecules are released into the immediate microenvironment and activate receptors for various pathways. Historically, PRP has been applied to wound beds to promote healing of complex wounds. Over the last decade, it has served as a valuable therapeutic tool in various specialties such as maxillofacial surgery, plastic surgery, orthopedics and sports medicine. Only recently has PRP been utilized for dermatologic purposes, more specifically, for the treatment of male and female pattern hair loss. In this review, we discuss molecular and cellular pathways upregulated by PRP important in hair folliculogenesis, and examine clinical evidence from all previously published studies involving the use of PRP for pattern hair loss.